I am wondering, what is the single or overbearing issue you have with your insurance or your health care as it stands?

For me it is cost, and the inability to have a competitive environment on cost. If you've ever asked a provider how much your service was going to cost and received a dumbfounded look as a response you know what I mean.

Office visits, medical procedures and prescriptions seem exempt from having to supply a cost quote or estimate on what you are about to have done or buy.

A typical response might be, "well it depends what insurance you have". Why? Why shouldn't the cost for any given service cost 'x' no matter what insurance a person has or doesn't have? Providers charge different amounts for different insurance plans as they get reimbursed a certain % based on said plan. Or certain procedures or exams get reimbursed a set amount by the insurer or government plan...but if you say you are paying cash the price for that service is drastically different than what the provider would otherwise be getting from the insurance provider.

If you are sitting at the doctor's office and you need a prescription, they ask where to send it? Why can't I say, "depends, how much if Village Pharmacy, how much is Rite Aid, how much is it at Walmart?"

The cost for goods and service relationship in medicine and medical care is so detached from the people receiving it.

When you need a repair on your car, or your home. Or considering a large purchase...a car, a major appliance. Or travel, hotels...airfare. In everything else in life we weigh one cost vs another cost and make decisions based on what is important to us in that equation, cheaper isn't always better, sometimes there is a reason to pay more, other times there is not. But in medical care and drugs we go into it completely blind of the costs and as a result providers and facilities do not have any real competition and therefore have no incentive to keep prices down.

Sure maybe the urgent care place is competing with the emergency room. Or maybe one pharmacy is competing against another. Maybe ABC MRI place is competing with the XYZ MRI place. And one out patient facility is competing with a different out patient facility...but patients have no way to analyze the cost of one vs the other and really doctors and medical providers are essentially isolated from competition and having to provide cost estimates.

That is something I would like to change.

Every prescription from your doctor should be able to be shopped at any pharmacy against published prices.

Every service performed or scheduled should be accompanied with an complete estimated cost for the service (including facility charges, individual doctor fees, anesthesiologist, etc).

And there should be one cost for all. Cash, uninsured, cadillac insurance plans, bare bones insurance plans, medicare, whatever, the base charge for anything and everything should be the same. Why charge one person one price for penicillin and then charge somebody else a different amount for the exact same thing?

quote: Why Can’t The Market for Medical Care Work Like Cosmetic Surgery?
By Devon Herrick Filed under Health Alerts on June 17, 2013 with 46 comments

Americans see their doctors more than 1 billion times a year &#8213; and spend nearly $300 billion on physician services &#8213; but they rarely discuss the price of a given service with their physicians in advance of receiving treatment. It gets worse. Although only about 10 percent of health care expenditures are spent on physicians’ services, doctors are the gate keepers to virtually all care that is provided to patients &#8213; including MRI scans, lab tests, hospital admissions and surgeries. Yet doctors rarely provide a list of prices for goods and services they provide or discuss the prices of the procedures they order. Patients don’t bother to shop for medical care, and doctors don’t advertise their prices because nearly 90 percent of patients’ tabs are paid with other people’s money.

However, when patients pay their own medical bills, they act like normal consumers &#8213; comparing prices and looking for value. And when patients act like prudent consumers, doctors who want their patronage must respond by competing on prices, convenience and other amenities.

Consider cosmetic surgery, one of the few areas of medicine where consumers pay out of pocket. The inflation-adjusted price of cosmetic medicine actually fell over the past two decades — despite a huge increase in demand and considerable innovation [See Figure]. Since 1992:

The price of medical care has increased an average of 118 percent.
The price of physician services rose by 92 percent.
The inflation rate, for all goods and services, as measured increased by 64 percent.
Yet cosmetic surgery prices only rose only about 30 percent.

HA1-06-17-2013

The price of cosmetic medicine was held in check by a variety of competitive forces: Doctors who perform cosmetic services quote package prices, and generally adjust their fees to stay competitive. The industry is constantly developing new products and services that expand the market and compete with older services. As more cash-paying patients demand procedures, doctors rush to provide them. There are few barriers to entry in cosmetic surgery. Any licensed physician can enter the field.

Entrepreneurial physicians are also on the lookout for new ways to market their services. Consider the ubiquitous deal-of-the-day emails, where Groupon and LivingSocial offer goods and services to subscribers at greatly reduced prices. These daily deal promoters offer numerous medical-related services, including Botox, corrective eye surgery, dental teeth cleaning, teeth whitening, laser hair removal, laser facial resurfacing, cosmetic fillers, spider vein and brown spot removal at highly discounted prices. This defies the conventional wisdom that a doctor would never advertise a bundled cash price — much less extend the offer to hundreds of thousands of random people sight-unseen. Yet the offers land in millions of email inboxes every day, and competition is fierce.

Consider botulism toxin injections, such as Botox and Dysport. According to surveys by the American Society of Plastic Surgeons, the average fee to administer botulism toxin was $369 in 2012, compared to $365 a dozen years earlier in 2000. Groupon and LivingSocial have occasionally offered Botox deals for as little as $99, with $149 quite common.

Another competitive service is laser skin resurfacing, which cost about $2,556 in 1996, according to the American Society of Plastic Surgeons. Physicians began offering less-invasive, fractional laser resurfacing that reduced recovery time. The cost of fractional laser skin resurfacing fell to $1,113 by 2012. Yet, couponing websites have offered numerous laser resurfacing deals for only $299. One Dallas-area Med Spa even offers this service, available with a one-year membership, for as little as $149 — a mere fraction of the cost elsewhere.

Wherever there is price competition, quality competition tends to follow. Take corrective eye surgery. From 1999 (when eye doctors began performing Lasik in volume)HA2-06-17-2013 through 2011, the price of conventional Lasik fell about one-quarter due to intense competition. [See Figure] Eye surgeons who wanted to differentiate themselves from other surgeons, and charge more, began to provide more advanced Custom Wavefront Lasik technology using IntraLase (a laser-created flap). By 2011, the average price per eye for doctors performing Custom Lasik was about what conventional Lasik had been more than a decade earlier; but the quality is far better. Occasionally an eye surgeon will offer a daily deal at half this price.

One criticism skeptics often voice in discussions about fostering patient consumerism is that a patient having a heart attack is not in a position to shop for the cheapest cardiac care from the back of an ambulance taking him to the emergency room. Few people would disagree. But only about $1 out of $20 is spent on patients who enter the health care system through the emergency room door.

Consider the experience of an insured patient whose doctor orders an abdominal CT scan. Receiving this service at a hospital outpatient department could cost the patient (or her health plan) nearly $3,000 depending on whether the patient’s deductible has been met. Yet this same service is available outside the hospital at a medical imaging center for prices that are often 85 percent less. Few health plans provide the tools for enrollees to compare prices and few patients have an incentive to ask about prices.

Doctors and hospitals don’t quote prices and don’t compete on price because most patients are largely insulated from the adverse effects of not making price comparisons and acting like consumers. Both economic studies and common sense confirm that people do not shop carefully and prudently when someone else is picking up the tab. The contrast between cosmetic surgery and other medical services is important. One sector has a competitive marketplace and stable prices. The other does not.

quote:In that you mean taking advantage or annual physicals and preventive check-ups? They are listed on your plan?

Yes they are on my plan and yes getting a healthy young person to get checkups, annuals etc.

And I guess that is the root of one of the problems with Obamacare is it not? Making young, healthy people pay for something they probably don't want or think they need. I could be wrong.

Ponder this: Medical Insurance can never be free market because in an emergency can be turned away from a hospital/ER. So the bet that I'll never need this is hedged by all of society. Until we as a society will turn away someone who is not financially able to pay the point is moot They will then have their illness treated for free.

My other peeve is that insurance is tied to employment but not for everyone. This limits business growth/expansion and job options for people - as well as career choices. Whomever ends up paying for it (through taxes; personal consumption) this should be unlinked.

My real take is that we should have a basic level of national health care with the option to buy into higher levels of care. And the basic level has to be at a level above Medicaid - because only the hospitals and not the providers get paid enough to survive.

How to fund this? The country needs to decide. But we are the only civilized nation without it - what is happening now is a shell game. This reality needs to be faced

I would say that we truly do not understand the pros and cons of Obamacare v Trumpcare v The way it was before. How can anyone predict and measure whether it has a positive or negative impact? You have to wonder why we allow ourselves to get worked up over something we can only speculate about.

quote:I would say that we truly do not understand the pros and cons of Obamacare v Trumpcare v The way it was before. How can anyone predict and measure whether it has a positive or negative impact? You have to wonder why we allow ourselves to get worked up over something we can only speculate about.

That is part of what I alluded to. Every "system" creates winners/loser. Those who can obtain insurance at a somewhat reasonable price; those who can't. Who gets subsidized/who doesn't.

In NY State there is only one carrier who will sell PPO insurance to small businesses. When they stop it will be impossible as a small business to obtain "good insurance." At any price. Two years ago I looked into the exchange - it wouldn't allow me to purchase the higher level (Gold/Platinum) plans at any cost. Only bronze HMO

Why are democrats fighting tooth and nail to save a collapsing unsustainable healthcare program. Obamacare in many states has only one single provider. The rest of the insurers bailed out because of skyrocketing costs.

Rather than work with republicans on replacement, they are wanting to save this bloated monument to liberal democratic policy.

Why are democrats fighting tooth and nail to save a collapsing unsustainable healthcare program. Obamacare in many states has only one single provider. The rest of the insurers bailed out because of skyrocketing costs.

Rather than work with republicans on replacement, they are wanting to save this bloated monument to liberal democratic policy.

FOX talking points. You might want to study a bit more from CBO to get a broader perspective.

Republicans worked well with Obama when he was attempting to pass health care reform? Dems should cave and work on this new trophy of a plan.

Goob - Will you be one of the 24 million projected to lose health insurance? Do you think that reflects favorably on Trumpcare / Ryancare?

Watched The Charlie Rose show last night and David Brooks of the New York Times was one of the guests. The conversation focused on Trump in general and also the republicans proposed health care plan. This quote from David Brooks for me sums up the GOP health care plan, “Introduces more risk into people’s lives and takes away social support.”

As Congress readies legislation to repeal and replace the Affordable Care Act (ACA), Congressional Budget Office (CBO) estimates will play an important and respected role as they did in the passage of the law in 2010. We now know that many of CBO’s projections of important aspects of the ACA have significantly differed from actual outcomes. In this piece, I highlight CBO’s key past errors in projecting effects of the ACA. They can largely be grouped into two categories. First, CBO projected that the exchanges would be stable by now with more than twice as many enrollees as they currently have, rather than suffering from severe adverse selection in most states as they now are. Second, CBO projected that the ACA Medicaid expansion would be much smaller and less expensive than it has turned out to be.

These errors were caused by two primary mistakes in CBO’s model and assumptions. First, CBO significantly overestimated the degree to which the individual mandate would induce relatively healthy people with middle class income to buy coverage in the exchanges. Second, CBO failed to anticipate that states would respond to the federal government’s elevated reimbursement rate for the Medicaid expansion by maximizing enrollment and paying insurance companies extremely high payment rates for this population. CBO has not yet explained if or how it has corrected its models for these past mistakes, but it should do so if it wants to improve confidence in its estimates of repeal and replace legislation.

Exchange Enrollment Much Less Than CBO Projected

When the ACA passed in 2010, CBO projected 21 million people would be enrolled in the exchanges in 2016. After the Supreme Court ruled that the Medicaid expansion was optional for states and not compulsory, CBO increased its projection of 2016 exchange enrollment to 22 million as some people who would otherwise have been enrolled in Medicaid in non-expansion states were then expected to enroll in the exchanges instead. Exchanges plans have proved much less attractive than expected as enrollment will average only about 10 million people this year. This means that CBO’s last projection of exchange enrollment before the exchanges opened overshot actual 2016 enrollment by 120 percent.

In a briefing to congressional staff on the effects of repealing the ACA that I attended as a Senate staffer in June 2015, I asked CBO about their then-projection that exchange enrollment would nearly double between 2015 and 2016. They responded that this was largely because of both an increase in awareness of the individual mandate and the increase in the associated tax penalty. In stark contrast to the projections of CBO and others, enrollment barely increased between 2015 and 2016.

CBO’s model has consistently and significantly overestimated the effect of the individual mandate in inducing people to enroll in the exchanges. Since higher income people were supposed to be more affected by the mandate (the penalty increases with income), a less effective than expected mandate means that exchange enrollees are also much poorer than expected. If CBO has not adequately adjusted its model for its mistake about the effectiveness of the mandate, its estimates of bills to repeal and replace the ACA—which will almost certainly eliminate the individual mandate—will continue to incorporate this source of inaccuracy.

Insurers Performance Much Worse Than CBO Projected

In February 2014, one day before a congressional oversight hearing examining the ACA’s risk corridor program, CBO released an estimate that the risk corridor program would net the federal government $8 billion over three years. CBO’s estimate assumed that insurers would be quite profitable selling exchange plans since insurers with “excess” profits contributed to the program while those with “excess” losses received payments from the program.

It turns out that CBO was significantly mistaken about insurer profitability. Insurers have incurred large losses on ACA plans, losses which have grown over time. These losses resulted in a $2.5 billion risk corridor deficit in 2014 and resulted in a $5.8 billion deficit in 2015. The large losses have also driven many insurers from the exchanges.

Reinsurance Program Subsidies Much More Generous Than CBO Projected

Insurers’ losses in 2014 and 2015 would have even been larger if not for receiving larger per enrollee payments through the reinsurance program than expected. The reinsurance program compensated insurers for a large share of the cost of their most expensive enrollees. CBO projected that reinsurance payments lowered premiums by about 10% in 2014. In an April Mercatus study I coauthored, we found that net reinsurance payments equaled about 20% of premiums—double what CBO expected. CBO’s estimates of insurer profitability look even worse since the agency significantly underestimated reinsurance payments as a percentage of premiums.

Medicaid Expansion Enrollment Much Greater Than CBO Projected

Since the exchanges have enrolled so few relative to expectations, the vast majority of the newly insured are enrolled in Medicaid. The figure below shows CBO’s most recent estimate of Medicaid expansion enrollment along with CBO’s 2010, 2014, and 2015 estimates. The figure—as well as the one on spending—adjusts CBO’s previous year estimates for its current assumptions about state adoption of the expansion. (Currently 31 states have adopted the expansion.) This adjustment allows for a better intertemporal comparison because it holds constant CBO’s assumptions about the percentage of the newly eligible Medicaid population residing in expansionary states.

Medicaid expansion enrollment is much higher than CBO expected when the ACA passed in 2010, and it is also significantly higher, particularly in 2017 and beyond, than estimated in both CBO’s 2014 and 2015 reports. Essentially this means that far more people—roughly 50% more—have enrolled in Medicaid in the states that expanded than expected by CBO.

Medicaid Expansion Spending Much Greater Than CBO Projected

In addition to higher-than-expected enrollment, spending per newly eligible Medicaid enrollee is much greater than CBO expected. As I wrote in July when the Obama administration released the 2015 Medicaid actuarial report, government spending on newly eligible enrollees equaled about $6,366 in 2015—an amount 49% higher than CMS’s projection of $4,281 from just one year earlier. In April 2014, CBO projected the Medicaid expansion enrollee average cost would be approximately $4,200 in 2015, a number very close to the erroneous CMS projection.

Both higher-than-expected enrollment and spending per enrollee has resulted in the Medicaid expansion being much more costly than projected. For example, in April 2014, CBO projected that the Medicaid expansion would cost $42 billion in 2015. The actual cost was approximately $68 billion, about 62% higher. The figure below shows CBO’s past projections of federal spending on the Medicaid expansion, again adjusting CBO’s previous year estimates for its current assumptions about state adoption of the expansion.

Medicaid expansion is proving much more expensive than CBO expected, largely because the agency failed to anticipate how states would respond to the elevated reimbursement rate for ACA Medicaid expansion enrollees. Many states have set very high payment rates to insurers for the expansion population with the cost dispersed to federal taxpayers.

More New Medicaid Enrollees Were Already Eligible Than CBO Projected

Recent research suggests that only between 30% and 40% of new Medicaid enrollees in 2014 were made eligible for the program by the ACA. In contrast, CBO’s most recent estimate projected that 13 million people would be added to Medicaid in 2016 because of the ACA—11 million, or 85%, as newly eligible and 2 million, or 15%, as previously eligible. This large discrepancy has significant implications for the proper share of federal and state spending as well as the practical implications of repeal.

Previously eligible but unenrolled Medicaid recipients could generally enroll at any time including at the point of needing medical care, meaning that the practical effect of repeal on coverage loss may be significantly overstated. To put it simply, many of the newly covered Medicaid recipients will remain eligible even if the ACA is repealed without a replacement.

Economic Growth After Obamacare Much Lower Than CBO Projected

In January 2010, CBO projected that growth in real gross domestic product (GDP) would average 3.2% from 2010 to 2016. By way of comparison, the annual GDP growth rate after the first six years of another severe recession (1981-82) averaged 4.6%.

Economic growth after the Great Recession has been anemic by historical standards and relative to expectations. As the figure below shows, annual real GDP has increased just 2.1%, 50% below the average growth rate predicted by CBO and less than half the growth rate during the Reagan recovery. The weak economic recovery has produced lower health care spending, and thus lower health insurance premiums, than would have resulted with a stronger recovery.

Conclusion

Projecting the economic impact of major pieces of legislation is a difficult task with substantial amounts of uncertainty. To its credit, CBO acknowledges this, even as there is a tendency elsewhere to treat CBO estimates as gospel. Since CBO estimates will once again play a prominent role in the coming ACA repeal and replace debate, it is important to appreciate the large degree of uncertainty and to understand CBO’s key mistakes estimating the ACA. In particular, it would be good to know the steps CBO has taken to correct for its two biggest mistakes—overestimating the effect of the individual mandate and failing to anticipate how states would respond to the elevated reimbursement rate for the Medicaid expansion population. CBO should then inform lawmakers how it has adjusted its model and assumptions. And irrespective of CBO’s methodological changes, lawmakers should proceed with full awareness of the limits of CBO’s projection capability.

quote:CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under the legislation than under current law. Most of that increase would stem from repealing the penalties associated with the individual mandate. Some of those people would choose not to have insurance because they chose to be covered by insurance under current law only to avoid paying the penalties, and some people would forgo insurance in response to higher premiums.https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestima
te/americanhealthcareact.pdf

Not sure if CBO quantifies what "most" of 14 million is, but taking that at face value..."most" of the 14 million people losing coverage in 2018 do not want coverage. And then some other smaller group of people compared to "most" would lose it due to rising premiums.

As I think most of us remember, ACA was facing challenges beyond 2016...before the election, even when Hillary was a projected POTUS winner, ACA was going to be facing problems. CBO word alot of their projections compared to "current law", but the current law of ACA was on thin ice, not from Republicans in Congress, but from reality acting like a loosening wrench on the nuts and bolts of the plan.

Sept 2016

quote: excerpt:

Next year is considered crucial by Obamacare advocates. A number of insurers intend to exit Obamacare marketplaces, and many insurers remaining on those exchanges plan to hike their premium prices more sharply than in past years.

While federal health regulators have noted that more than 80 percent of Obamacare exchange customers get subsidies that can shield them totally or largely from premium price increases, millions of unsubsidized customers have no such protection.

It's going to be a lot easier for people to pick an Obamacare plan in 2017, if only because there will be fewer to choose from.

One of the biggest drivers of increased healthcare costs is the lack of competition in some markets. This problem is acutely present for the Affordable Care Act's public insurance exchanges, according to a new study by Avalere Health.

While many will hail adding people to Medicaid coverage, many with that coverage find it hard to get care as they are denied access by providers since they are reimbursed only about 40% of their services under ACA.

January 2015:

quote:excerpt:

Primary care doctors face pay cut

Family doctors who treat Medicaid patients will see steep drops in payments from the federal government that could make it tougher for millions of low-income people to find care.

Reimbursements from Medicaid will shrink an average of 43 percent starting in January, when the federal government’s temporary raise for primary care doctors is set to expire.

The federal government had raised its reimbursement rates to entice more doctors to accept Medicaid patients under ObamaCare. Patients with Medicaid have been historically known to cost healthcare providers far more than they are repaid for the treatment, causing some doctors to turn away patients. http://thehill.com/policy/healthcare/228294-obamacares-2015-challenges

Now it is certainly fair to take issue with the Republicans and Trump because someone disagrees with the direction they are taking their repeal and replace compared to say the direction Hillary Clinton would've went. Either way, it is undeniable that ACA would've been highly unstable and even ineffective going forward without action.

Our experience with the first six and a half years of the Affordable Care Act already tells us whether it will work.

Despite the law’s goals of containing costs and making health care affordable, it’s proven to be too expensive to be sustainable, overly complex and bureaucratic, and a gift to the private health insurance industry and other corporate stakeholders in the medical-industrial complex.

To be fair, the ACA has brought some kind of coverage to about 20 million Americans, in good part through the expansion of Medicaid in 32 states (including D.C.) and the subsidized exchanges. But its negative results far outweigh its gains, as shown by these data points:

> We still have 29 million uninsured Americans (compared to 48 million at the start), plus tens of millions underinsured.

> Insurance plan deductibles and co-pays have sharply increased, deterring people from seeking necessary care. A brand new market is opening up, “gap insurance,” to cover what is not covered in today’s market - insurance for those who have insurance.

> Narrowed networks under the ACA have forced many millions of patients to change their desired physicians and hospitals.

> The ACA has accelerated a national trend of corporate consolidation of insurers and hospitals, with growing market and political power.

> The ACA’s regulation of health insurers has been lax, leaving insurers many ways to game the system (e.g. by overstating the health risks of their enrollees) in their self-interest.

> Expanding hospital systems, facing less competition, are free to charge much higher prices, by up 40 percent to 50 percent.

> Pharmaceutical drug prices have been sharply increasing, often shockingly so. A one-year course of cancer drugs often exceeds200,000, forcing many patients to choose between bankruptcy and treatment.

> The costs of insurance and health care now exceed25,000 for a family of four covered by an average employer-sponsored PPO plan.

> Overpayments to privatized Medicaid plans are endemic in more than 30 states, often involving unnecessary and duplicative payments.

> The ACA’s accountable care organizations have failed to contain costs and improve quality of care.

> Most of the nonprofit co-ops established under the ACA have failed.

> Sign-ups for ACA coverage on the exchanges have fallen far short of expectations - just 11 million this year compared to 24 million forecasted, with many people unable to afford even subsidized coverage.

> Premium increases of 50 percent or more for 2017 are being reported in a number of states, including Minnesota, while many insurers are exiting their markets.

> Given this dysfunctional reality under the ACA, it’s remarkable that neither major political party has a plan to truly fix the situation.

If elected, Hillary Clinton proposes to bring on the public option (which can’t possibly succeed against the overwhelming market share of a subsidized insurance industry), increase subsidies, add new tax credits for deductibles and co-payments, and lower the age for Medicare eligibility to age 55. These tweaks would not reverse the huge private bureaucracy bent on increasing profits in markets subsidized by taxpayers.

Given the opportunity, Republicans would repeal the ACA with no credible plan for replacement - relying on such long-discredited approaches as consumer-directed health care, health savings accounts, high risk pools, selling insurance across state lines, and giving states more leeway with block grants.

We should have learned by now that segmented risk pools designed for profits by private health insurers will never provide universal access to affordable health care in this country.

Virtually all advanced countries around the world learned this long ago with one or another form of universal health insurance.

Multiple studies have demonstrated that in the U.S. we could save about $500 billion a year by enacting a nonprofit single-payer national health program that streamlines administration. Those savings would be sufficient to guarantee everyone high-quality care, with no cost sharing, on a sustainable basis. The system could also negotiate lower drug prices.

Studies over the past two decades have shown 3 of 5 Americans supporting an improved version of Medicare for all. Support for single payer is also growing among doctors and other health care professionals. Yet the Expanded and Improved Medicare for All Act, H.R. 676 (Rep. John Conyers’ bill), with 62 co-sponsors, sits neglected in a House committee.

Until we recognize that the largest possible risk pool is required to implement universal coverage in the public interest, and that the private health insurance industry is on a death march, we cannot make necessary health care available to all Americans.

Can’t we get to real health care reform on a nonpartisan, win-win basis?

John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans

quote:CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under the legislation than under current law. Most of that increase would stem from repealing the penalties associated with the individual mandate. Some of those people would choose not to have insurance because they chose to be covered by insurance under current law only to avoid paying the penalties, and some people would forgo insurance in response to higher premiums.https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestima
te/americanhealthcareact.pdf

Not sure if CBO quantifies what "most" of 14 million is, but taking that at face value..."most" of the 14 million people losing coverage in 2018 do not want coverage. And then some other smaller group of people compared to "most" would lose it due to rising premiums.

If it comes down to it, people can go to the walk in emergency care places. Find a good one with Doctor's who are reasonably knowledgeable and just utilize them. I may need to do that later this year. If it comes to that, I will go in as an informed health care consumer. Most Doctors are just not that knowledgable. I told the internist I was losing my hair and thought it could be a thyroid or endocrine problem, I suggested he check my prolactin levels. He got pissed off and only did regular thyroid tests which showed nothing. He had nothing to offer me, somebody else told me take prenatal vitamins, they fix it if your hair is falling out. All it has in there is folic acid and B vitamins, but in the formulation they have it, it works. Anybody else losing your hair, get some prenatal vitamins and take one per day. Within a week or so, you will probably see improvement.

Yeah that is a minor thing, but it is important. After some of what I have been thru with other things I am mostly just disgusted with the medical profession, though I will say there are still some great Doctors, over the 6 months I met a few of them who are very impressive, and I don't need to offer any suggestions, they know their stuff.

[Edited on 3/15/2017 by gina]

____________________"Mankind is a single nation" "Allah did not make you a single people so he could try you in what he gave you, to him you will all return, he will inform you where you differed". Quran Chapter 2 Sura 213

I don't know what the solution for this mess of a system we have. I'm open to a national single payer system, but I also want everyone to have some skin in the game on their health and consequences for certain decisions they make (good or bad). I think really the over riding thing I want is for costs to go down. Not just costs that the individual is exposed to, but net costs that 3rd party payers or anyone are also responsible for. Hospitals with 24 hour ERs having unpredictable inflows and corresponding expenses will always be a challenge and there is a certain level of cost shifting from uninsured and Medicaid patients to everyone else. But outside of an ER billing department, it would certainly seem to me that costs shouldn't be that hard to reign in on just about everything else. We need cost transparency in medicine and health care and I think we need people to care what these costs are to make decisions off of just like we do about everything else in life.

Stories on the Surgery Center of Oklahoma have been out there for a while, but it fits into this thread. They are still functioning today as they were in 2013 when this piece was written.

In Oklahoma City, one surgical center is successfully reducing the price tag for their procedures by thousands of dollars &#8202;and encouraging nearby hospitals to follow suit.

What’s the secret?

The two doctors who started the Surgery Center of Oklahoma, Dr. Keith Smith and Dr. Steven Lantier, are committed to charging fair prices, and they founded their hospital with the goal of price transparency. “What we’ve discovered is health care really doesn’t cost that much,” Dr. Smith told KFOR-TV. “What people are being charged for is another matter altogether.”

They have been posting all of their prices online for the past several years, and they charge significantly less than other hospitals in the area.

“When we first started we thought we were about half the price of the hospitals,” Dr. Lantier said. “Then we found out we’re less than half price. Then we find out we’re a sixth to an eighth of what their prices are. I can’t believe the average person can afford health care at these prices.”

After comparing the Surgery Center’s prices with the bills for the same surgical procedures at other Oklahoma City hospitals, KFOR-TV confirmed just how wide that gulf is. For example, a $3,500 breast biopsy at Surgery Center of Oklahoma will cost $16,244 at nearby Mercy Hospital. A hysterectomy jumps from $8,000 at Surgery Center to $37,174 at Integris Baptist Hospital. And the OU Medical Center consistently charges about $15,000 more than what the Surgery Center does for common procedures like open fracture repairs and gall bladder removal.

The two doctors started somewhat of a medical bidding war after they started publicizing their pricing options. People began traveling from out town and even from out of state to take advantage of the much lower bills at the Surgery Center&#8202;—&#8202;and other hospitals took notice. At least five other Oklahoma City-area medical facilities started posting their own prices online, and some of them are even beginning to lower their bills as their patients push for price-matching.

“Hospitals are having to match our prices because patients are printing their prices and holding that in one hand and holding a ticket to Oklahoma City in the other hand and asking that hospital to step up,” Dr. Smith pointed out.

There are some caveats accompanying the Surgery Center of Oklahoma’s business model. What works for surgery centers may not necessarily work for larger hospitals, since surgery centers tend to focus on elective procedures that are a bit more predictable than the range of care needed in an emergency department. And, since the federal Medicare program doesn’t currently support this type of online pricing for their beneficiaries, the Surgery Center can’t accept any patients with Medicare or Medicaid plans. Only those with private insurance, or those who lack insurance altogether, may patronize the facility. Some critics say that allows the Surgery Center to cherry-pick the healthiest or highest-income patients.

But on a broader scale, more price transparency in the health care sector is sorely needed. New government data has confirmed that hospital pricing is often completely random, with the most expensive hospital in the country charging about four times more than average for no apparent reason. When it’s not clear what health services cost, doctors are more likely to recommend and patients are more likely to agree to expensive and unnecessary tests and procedures. And most patients can’t easily shop around to make the most informed decisions about where they want to get their care.

Provisions under Obamacare will attempt to spur more transparency in this area to both equip Americans with more information about their health care and convince hospitals to make their prices more competitive. Some private hospitals, like the handful in Oklahoma City, are already taking it upon themselves to get started.

Part (but not all) of the ability of the asc to charge less is because they can turn away the uninsured; decide which insurances they choose to participate in; and don't need to stay open 24/7 for Emergencies. Cherry Picking is a very lucrative position for a business to have.

Cherry picking makes health insurers wadZILLions of dollars. And even if all the different insurance companies would use 1 single standardized form for application and submitting claims it would save MILLIONS.

I work in healthcare. I am not eager to see the return of mass uninsured, there is no reason why hospitals should provide free care for people. Insurance companies make money off of this. They cherry pick and someone else gets burned for the charges.

We need to get away from Damage Control Healthcare and into wellness care, we need single payer, and we need to get rid of obscene CEO salaries and bonuses and $500 bags of saline.

When did the cost for one's medical cost become somebody else's responsibility? I remember when I was a kid people would just talk about hospitalization insurance, but everything else was the individual's responsibility. Seems to me like the health insurance industry in and of itself has led to the cost explosion. The very thing that supposedly allows people to afford medical costs is the exact same thing that is driving up the cost.

Like I said when somebody else is paying, who shops around on price (to the extent you can?). When you are paying out of pocket, don't you shop on price? We saw how much "business" the Surgery Center of Oklahoma got from their "competitors" when they started publishing the rates for their procedures - and we see how much other places were charging.

Surgery Center of Oklahoma doesn't turn away the uninsured, that is if you have a means to pay for it. Sometimes uninsured doesn't have to mean indigent. Everyone makes decisions in their lives, what to spend, where to spend. Why shouldn't people plan, save and budget for their potential medical costs? Don't we do that when our homes and autos need repaired? But for some reason, when it comes to medical costs people don't want to think about it, oh that should be the government's or the insurance companies or somebody else's responsibility. When we have the patient caring about the cost is when we can have cost reductions. Maybe if we could rein the prices in we could get closer to a system where people could afford the costs. Instead we get a place like Surgery Center of Oklahoma charging $3500 for something while somebody else is charging $16,244 for the same thing. Or $8000 instead of $37,174 at another place for the same thing!

ER Hospitals are a different story, I get it whether there are zero people there or 50 people there they are open and staffed and the people and situations they face are unpredictable.

And I guess it is all tied together. I still think overall price transparency should be the goal. Why am I the crazy one when I ask my doctor or whatever facility I am at how much it will cost ahead of time? They shouldn't be incapable of offering a price estimate.

The health insurance and the medical industry in this country is so complicated and confusing, the IV bag story really pisses me off. Just like charging 5 different rates for the same thing for 5 different people. All Washington ever does is just add more and more layers of complexity onto the system, which seems to lead to higher and higher net costs. I think it needs stripped down, exposed and we need to start over on how medicine is administered, billed and paid for in this country.

Again re: surgi center of Oklahoma. People can pay if they are uninsured; many people can afford say a Colonoscopy or Arhtroscopy.

But those who are indigent get it for free in an Emergency Basis only at the hospitals. And the $500,000 complicated open heart surgery for the indigent/uninsured never enters into the bottom line at the surgi center.

The $500 saline bills pay for free saline for the uninsured.

The system is nuts; there is no transparency. But unless everyone has insurance and/or hospitals have the right to turn away the indigent none of this can ever get fixed.

I've said it many times here but ALMOST NO ONE CAN AFFORD TO PAY FOR TRULY EXPENSIVE CATASTROPHIC ILLNESSES. PEOPLE WHO "ROLL THE DICE" WITHOUT INSURANCE REALLY AREN'T ROLLING THEM

Hospitals can't turn people away because of something Reagan passed stating that ability to pay can't be considered when somebody comes to the hospital for care.

Is that where costs started ballooning? Something, some event in history had to be the marker for cost escalation that continues today. Growth of employer sponsored plans? Insurance profit greed, when did that really kick in?

I'm just trying to see if there is a line in the sand where people had a certain level of responsibility to pay for most of their normal medical and drug costs, and were able to mostly afford it - to where we are now.

As to rolling the dice...

...if someone has no health insurance, no medicare, no medicaid and goes to ER they do get care and then also get the bills. If they can't pay those bills it get turned over to collection agencies probably for pennies on the dollar then the hospital has to look to recoup those lost charges somewhere else. For the individual, some people might do their best and work out some cost reduction agreement and a payment plan, others will surely just have to fold under the debt they've created and may have to declare bankruptcy to escape the costs their care created. So technically, the uninsured do have something to lose if it comes down the result of having to go bankrupt. So there is some dice rolling involved still, correct?

On the other hand, if one can get on Medicaid then they go to the ER, get care and get no bills and the government pays a % of the bill and the hospital either eats the cost of the balance or shifts the cost to the other payers. Which, I would suspect that hospitals still look to recover the unpaid part of medicaid bills somewhere right? They are shifting those costs to the saline bags just like they are for uninsured no?

We're caught in this endless loop of public debate about who pays. Who pays isn't the issue. The costs are the issue, and we never address that.

If medical costs were reduced by 1/4 - still making us one of the most expensive countries for health care - the number of people who could be treated and cared for with the same current dollars would more than cover everyone.

I'm no fan of gov't run single payer for the US. It might work in some places, but I seriously doubt it would here (see the VA). We have un-involved health care consumers because they haven't had to think much about their costs. That's the legacy of group buying, and a big contributing factor to why providers aren't faced with questions about how much something costs. If we stopped the group coverage, health care consumers would pay a lot more attention to costs, forcing providers to be much more visible in their pricing. Unless we stop the cycle of why one person can get charged 5x more than the next due to what insurance they have, this will never be improved.

____________________Obamacare: To insure the uninsured, we first make the insured
uninsured and then make them pay more to be insured again,
so the original uninsured can be insured for free.

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